After three years of private practice in a medically underserved area of rural Maine where I was on call virtually all of the time, I was exhausted. I moved to Central New York, where I worked for two years for an HMO whose medical care goals and standards did not match my own. I also found it very frustrating to work for someone else after having my own boss. I became disillusioned with the practice of family medicine altogether. I began to resent prepaid patients who, because their visits were "free," tended to overutilize the health care system. My attitude was not a healthy one, and I sensed that a complete break from patient contact was needed.

The solution seemed to lie in an advertisement for a physician to serve as a hospital surveyor for New York State's Department of health. The survey team, consisting of three nurses and myself, spent two weeks at each hospital in our region, trying to discover all the negative patient outcomes, flawed policies, and inadequate quanlity assurance programs that we could. We would then generate voluminous reports detailing the deficiencies we found. Needless to say, hospitals objected strenuously to the one-sided picture painted by the dreaded Statement of Deficiencies, which was released to the press (albeit edited to protect the guilty and to preserve patient confidentiality) under the freedom of information laws. The bad public relations that followed such a press release haunted a hospital for years, even generating new malpractice suits. The hospital had to respond to a flood of consumer outcries in addition to the fines and penalties imposed by the health department.

Merely hosting the survey team for two weeks disrupted the day-to-day hospital routine to the point that no other administrative work was accomplished. The team reviewed well over 100 medical records; observed nursing, medical, and ancillary personnel in action on the floors; conducted staff and paitnet interviews; and on occasion observed surgical and cardiac resuscitations. Surveyors were instructed to go on nursing units, unannounced, at all hours of the day or night, in order to catch staff off guard and doing something that violated state regulations.

The more violations uncovered, the better the survey team appeared to be doing its job, so we found many, all in the name of improving the quality of health care in New York hospitals. I think that our gestapo surveillance methods did improve care in the worst hospitals, but at a very high price. The level of antagonism between hospitals and the health department rose to feud-lid proportions.

Was this really a healthy environment in which to promote "quality patient care?" I began to think not. Consistently negative feedback--i.e., statements of deficiency, monetary fines, and threats of hospital closure--prompted reams of corrective paperwork and verbal promises to do better. However, I doubt that the level of care actually rose very much, especially when the professionals delivering that care were felling intimidated, defensive, and paranoid. Fear of reprisals from the health department paradoxically inhibited some hospitals' quality assurance activities. They reasoned that covering up problems would prevent further punitive actions by the state.

I grew frustrated and discouraged. The environment was oppressive; the persistent focus on negative patient outcomes was depressing. Where was the positive change that I had naively presumed was the goal of surveillance? I had a vision of quality assurance performed in an atmosphere of growth and support for creativity. I pictured a continual striving for excellence not hampered by punitive, almost vengeful, sanctions when the inevitable mistakes were made.

When an ad appeared in the local paper for medical director of a 100-bed municipal hospital, I was eager to apply and discard my policing role. The hospital's board and medical staff realized that my inside knowledge of the health department's working would help them stay in compliance with state regulations. I wanted the chance to use my suppressed problem-solving abilities to prove that quality assurance could be done in a positive and educational climate.

New York State hospital regulations charge the medical director with responsibility for all medical care in the facility. This, along with supervision of the medical staff and its quality assurance program, is an awesome undertaking, even for a physician familiar with the hospital. Being a total stranger meant that I had to start from scratch to build my credibility, forge alliances with key medical staff members, and learn the procedural systems already in place before even beginning to attempt improvements. Because the hospital had never had a full-time medical director, the staff wasn't too sure of my role or functions. Neither was I.

In this new role, I'm learning that listening is much more instructive than lecturing; that those who have been practicing medicine for 30 years generally are quite knowledgeable; and that most physicians care deeply about their patients, try their best under trying circumstances, and occasionally screw up anyway. When they do, they usually feel terrible enough on their own without external punitive action. Most learn from their mistakes. The ones who don't learn are dangerous. Most dangerous are the ones who never admit the possibility of an error. The really brave practitioners share their foibles with their colleagues so that other don't have to learn the hard way.

And that, to me, is the essence of peer review: sharing knowledge and providing positive feedback for a job well done. Occasionally, corrective action is necessary. Obviously, suspension and reduction of privileges are options of last resort, reserved for those who are ineducable because of poor attitude, incompetence, or impairment. The medical director serves as the "heavy" when disciplinary action is required. It's not fun, so one really has to believe in the goal of improving patient care to get through unpopular times.

It's too early for definitive judgments on my success, but there are some hopeful signs. Already I see changes in the medical staff's attitude toward quality assurance. This used to be a chore that physicians suffered through because "the state requires it." Now department meetings focus on educational case discussions. There is less griping about "all the irrelevant paperwork that keeps us from patient care." Physicians are beginning to see the connection between case reviews and improvement in quality of care.

After some initial reluctance, I generally feel accepted by members of the medical staff. They are beginning to come to me with problems rather than waiting for me to discover them. From the outset, the nursing staff seemed delighted to have someone who had the time to listen to the difficulties they were having with physicians and the authority to handle serious problems. Of course, many issues boil down to personality clashes, which can never be completely resolved. I've learned not to overreact after hearing only one side of a story. There is always another, usually reasonable, explanation for most "terrible" tales.

I am enjoying interacting with people in a more positive and creative way. I have even resumed some patient care responsibilities in my role as Director of Employee Health. This limited patient contact, unmarred by on call duties, has renewed my long-dormant passion for patient interaction. Sometimes we must lose a precious possession before we appreciate its value. It took 18 months without patient contact, without the stress of being on call at night, overtired and overworked, for me to rediscover what I enjoy most about medicine. In the process, I stumbled upon a new career, medical management, that I enjoy even more.

I hope that I never forget what I was like to be up for three nights in a row as a solo family practitioner, doing everything from delivering babies, to managing cardiogenic shock, to assisting in major surgery. I realized too late that physicians need to work in an environment conducive to their own mental and physical health or they will burn out, as I did. My goal now is to create and maintain an optimal environment for both the providers and the recipients of health care, at least in my small corner of the medical universe.

COPYRIGHT 1992 American College of Physician Executives
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